ORIGINAL ARTICLE

Swallowing function in patients with vertical hemipharyngolaryngectomy for hypopharyngeal squamous cell carcinoma Young-Hoon Joo, MD,1 Kwang-Jae Cho, MD,1 Jun-Ook Park, MD,2 In-Chul Nam, MD,1 Chung-Soo Kim, MD,1 Sang-Yeon Kim, MD,1 Min-Sik Kim, MD1* 1

Department of Otolaryngology–Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea, 2Department of Otolaryngology–Head and Neck Surgery, Inje University College of Medicine, Busan, Korea.

Accepted 12 September 2014 Published online 20 June 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23867

ABSTRACT: Background. The purpose of this study was to evaluate the long-term swallowing function in patients with vertical hemipharyngolaryngectomy (VHPL) for hypopharyngeal cancer. Methods. A retrospective review of 30 patients followed for more than 2 years with VHPL between 1998 and 2011 was performed. Results. Five patients (16.7%) experienced gastrostomy tube placement, 4 patients (13%) had pharyngoesophageal stricture, and 13 patients (45%) had aspiration pneumonia. There was a significant difference in the fraction of gastrostomy tube placement among type II VHPL (35.7%), type I VHPL (0%), and type III VHPL (0%; p 5 .014). Gastrostomy tube dependence was significantly associated with flap size (larger than

INTRODUCTION Vertical hemipharyngolaryngectomy (VHPL) is an organ-preserving surgery for managing select hypopharyngeal squamous cell carcinomas (HPSCCs).1 VHPL offers a wider resection margin with promising functional results. The resection includes removal of laterally localized extended pharyngolaryngeal tumors with immediate microsurgical reconstruction using a radial forearm free flap, including the palmaris longus tendon for glottis reconstruction. Second, it is important to understand that there are actually 3 types of VHPL performed for distinct indications (see Figure 1): limited VHPL (type I) involves resection at the lateral border of the conus elasticus to preserve both vocal cords; total VHPL (type II) includes removal of a vertical section of the thyroid cartilage through the anterior commissure to the upper border of the cricoid cartilage; and extended VHPL (type III) includes supraglottic laryngectomy (type IIIa) and/or partial cricoid cartilage resection (type IIIb). Resection of the structure responsible for laryngopharyngeal sphincteric functions predisposes patients to

*Corresponding author: M.-S. Kim, Department of Otolaryngology – Head and Neck Surgery, 505 Banpodong Seochogu Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea 137-040. E-mail: [email protected]

70 cm2; p 5 .043) and aspiration pneumonia (p 5 .009). A significant positive correlation was found between current smokers and aspiration pneumonia (p 5 .030). Conclusion. Type II VHPL, large flap reconstruction, and aspiration pneumonia had predictable values for gastrostomy tube dependence. Smoking status correlated with aspiration pneumonia. Better counseling and C 2015 vigilance concerning swallowing difficulties may be possible. V Wiley Periodicals, Inc. Head Neck 38: 191–195, 2016

KEY WORDS: hypopharynx, squamous cell carcinoma, reconstructive surgical procedures, deglutition, treatment outcome

swallowing disorders or aspiration, which can produce life-threatening complications, such as aspiration pneumonia. Dysphagia-related pneumonia can spiral into respiratory failure and sepsis, and represents a major source of morbidity and mortality in patients with head and neck cancer.2–4 Postoperative changes include transection of the superior laryngeal nerves and the pharyngeal constrictor muscles and formation of the anterior wall by suturing the resected hypopharynx and a free flap. The anterior elevating action of the larynx, which is present during the normal swallowing movement, is lost because of these anatomic changes. This causes failure to produce negative pressure in the region of the upper esophageal sphincter and a corresponding loss of the relaxation action.5 Dysphagia is one of the long-term complications after radiation therapy for HPSCC. These swallowing problems are attributed to the effect of irradiation on the soft tissues in the pharynx. Dysphagia is the sequelae of soft tissue fibrosis, neuropathy, and possibly myelopathy.6,7 A particularly incapacitating form of dysphagia is the pharyngoesophageal stricture. Among all head and neck cancer sites, patients with HPSCC are also most likely to develop pharyngeal dysphagia and pharyngoesophageal stricture because of radiation-induced fibrosis of the pharyngeal constrictors, larynx, and esophageal inlet, which predisposes patients to long-term swallowing dysfunction.8 These patients often require esophageal dilation to maintain pharyngoesophageal patency and are dependent on gastrostomy feeding.

HEAD & NECK—DOI 10.1002/HED

FEBRUARY 2016

191

JOO ET AL.

the Department of Otolaryngology–Head and Neck Surgery, The Catholic University of Korea, Seoul, from September 1998 to December 2011 were reviewed. Enrolment criteria included the availability of follow-up for >2 years postoperatively. Twelve patients were excluded because of a history of tumor recurrence after treatment or follow-up loss. The study population consisted of 30 patients. All free flap reconstructions were performed by the same surgeon (M.-S. K.). Indications and modalities for adjuvant treatment varied over time. Patients with a positive or a close margin, advanced T classification, lymphovascular invasion, perineural invasion, multiple nodal metastases, or extracapsular spread received additional chemoradiation. Additional radiation alone was performed in patients with a positive margin only or poor general condition. The patients were staged according to the 2007 American Joint Committee on Cancer staging system. Postoperative management of the tracheotomy and feeding tube was standardized. The first attempt at removal of the tracheotomy tube was performed by postoperative day 7. The patient continued to use a nasogastric tube as the primary source of nutrition and hydration. The swallowing act of the patients who underwent VHPL was evaluated using videofluoroscopy 7 to 21 days postoperatively. Oral alimentation was then initiated using pureed food with daily speech and chest therapy. Various airway protection maneuvers were trialed with varying textures and consistencies to develop a therapeutic swallowing and exercise program. Therapy included the Mendelsohn maneuver, effortful swallowing technique, and the supraglottic swallow maneuver.9 Patients were sent home once they could achieve normal oral alimentation. A gastrostomy tube was placed when a patient was unable to demonstrate the ability to maintain adequate hydration and nutrition through oral means alone for at least 4 weeks and for so long as there was any concern about swallowing safety. The follow-up period was 24 to 149 months, with a mean of 61 months. The hospital’s institutional review board approved this retrospective review of medical records.

Videofluoroscopic swallowing studies FIGURE 1. Schematic drawing of the types of vertical hemipharyngolaryngectomy (VHPL) based on the extent of resection. (A) Limited VHPL (type I). (B) Total VHPL (type II). (C) Extended VHPL C 2011 Ameri(type IIIa). (D) Extended VHPL (type IIIb). Copyright V

can Medical Association. All rights reserved. Reprinted with permission.

Patients with VHPL must learn a new way to swallow after the operation. Prolonged swallowing disorders and aspiration in many of these patients require extensive deglutition rehabilitation and temporary or permanent gastrostomy. Our purpose in this study was to evaluate the long-term results of dysphagia, pharyngoesophageal stricture, and aspiration pneumonia rates after VHPL.

PATIENTS AND METHODS Patients The clinical and pathological data of 42 consecutive patients diagnosed with HPSCC who underwent VHPL at 192

HEAD & NECK—DOI 10.1002/HED

FEBRUARY 2016

Videofluoroscopic images were recorded and analyzed with a model 7200 digital swallowing workstation (Kay Pentax, Lincoln Park, NJ). The recordings were completed by a radiologist in the radiology department. Three consistencies of food were given to each patient: water mixed with liquid barium (Polibar Plus liquid, barium sulfate suspension; Therapex) in a 3:1 ratio presented in a cup; approximately 10 mL of pudding mixed with paste barium (Esobar, barium sulfate cream; Therapex) in a 3:1 ratio presented in a spoon; and one quarter of a digestive cookie coated with barium paste. Two trials of each consistency were performed while videofluoroscopic recording took place. All patients consumed as many of the 3 consistencies of food as possible, with some consistencies excluded for certain patients because of anatomic constraints (ie, absence of dentition) or clinician-perceived clinical risk to the patient. Posterior bolus movement by the tongue, inflow of barium into the pharynx before swallowing, tongue base to posterior pharyngeal wall contact, pharyngeal wall contraction, laryngeal elevation, stasis in the epiglottic vallecula and pyriform sinus, stasis in the oral cavity after

SWALLOWING

TABLE 1. Demographic profiles of patients with vertical hemipharyngolaryngectomy. Parameter

No. of patients

%

17 13

56.7 43.3

30 0

100 0

23 4 3

76.7 13.3 10.0

27 3

90.0 10.0

20 7 3

66.7 23.3 10.0

22 8

73.3 26.7

12 14 4

40.0 46.7 13.3

27 3

90.0 10.0

17 13

56.7 43.3

Age, y 60